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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406208351
Report Date: 09/15/2021
Date Signed: 09/15/2021 10:21:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CHILDREN'S ACADEMY MONTESSORI SCHOOL, THEFACILITY NUMBER:
406208351
ADMINISTRATOR:TAMERA DAVISFACILITY TYPE:
850
ADDRESS:711 ROLLING HILLS DRIVETELEPHONE:
(805) 239-9790
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:40CENSUS: 40DATE:
09/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Tamera DavisTIME COMPLETED:
10:25 AM
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On 9/15/2021 at 9:28am, Licensing Program Analyst (LPA) Melissa Stewart arrived at the child care center to conduct an unannounced, Case Management inspection and met with Director, Tamera Davis. LPA conducted a Risk Assessment for COVID19 and all answers indicated no exposure to COVID19. LPA explained the purpose of the inspection. Director, two (2) staff and one volunteer were supervising 28 children in the preschool outdoor activity area. Director wore a face mask. As children and staff entered the classroom, LPA observed staff and children putting on face coverings.

On 9/8/2021, Director self-reported an incident to the Community Care Licensing office which had occurred that same day. C1 was running outside on the cement as children were lining up to come inside. C1 tripped on C1s own feet and fell extremely hard directly on C1s left knee. C1 was admitted to Twin Cities Emergency Room (ER) and diagnosed with a fractured femur.

On 9/9/2021, LPA Stewart conducted an unannounced inspection during which staff # 1 (S1) who observed the incident was interviewed. On 9/14/2021, LPA Stewart interviewed the parent of C1 who reported that they felt supported and appreciated the care provided by center staff. Based on interviews and observation of the location where the incident took place, it is determined the environment at the center nor actions of the center staff contributed to C1's incident.

No deficiencies cited today.

A copy of this report and appeal rights were discussed and left with Licensee, Tamera Davis, whose signature on this form confirm receipt of these documents.

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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